ADVANCED IMAGING TECHNOLOGICAL APPLICATIONS ON THE BATTLEFIELD
Conferences are Great Sharing Opportunities.
This is a Synopsis from a Recent Battlefield
Healthcare Imaging Workshop.
by Les Folio
The modern day battlefield has seen exponential modernization in medical technology, with diagnostic imaging among the fastest developing. This rapid technological epidemic has driven educational requirements to keep up with the changing applications. Medical imaging has transformed in recent battlefield health care to include multi detector computerized tomography (MD CT). Although CT has been commonplace in trauma management throughout the world since the 1980s, recent increases in detectors (16 and 64 slice for example), has led to exquisite anatomic and pathologic detail, providing trauma surgeons with guidance unparalleled with prior systems.
The unfortunate tradeoff with increasing resolution, however, is increasing file sizes and difficulty managing the data that has been addressed in prior MMT articles (“Teleradiology Roundtable.” Vol. 7, Issue 4. 2007). These advances and challenges have been addressed from a battlefield perspective in a recent focus session/workshop by Defence IQ, a division of IQPC. The name of the focus event was “Advanced Imaging in Combat” Focus Day and was held recently on June 25, 2008 in London, England, and preceded the Battlefield Healthcare conference.
The workshop was chaired by Colonel Les Folio, USAF, MC, SFS. Folio is an associate professor, radiology and radiological sciences at the Uniformed Services University of the Health Sciences in Bethesda, Md. He worked closely with Elana Hartle-Fishman conference director of Defence IQ. Hartle-Fishman was responsible for the logistics and overall coordination of the meeting.
Hartle-Fishman introduced Folio as opening speaker for the workshop as he presented on the application of advanced imaging techniques in combat and his recent experiences in Iraq. Folio discussed how advanced multidetector CT imaging can now guide trauma surgery better than ever before with 3-D and MPR (multi-planer reformat) imaging. He showed examples of how the volumetric imaging can help determine missile pathways from work he has done with a USU student, Chris Backus. The potential of ballistic trajectory analysis and damage control radiology has only started to be explored. After Folio, Professor Lorna J Martin provided a stunning presentation on forensic imaging technological developments of forenscan. She showed how low-dose whole body imaging applications are used in South Africa to assist forensic pathologists in determining cause of death. Martin is the chief specialist and head of division, forensic medicine and toxicology at University of Cape Town in South Africa. She demonstrated how the use of low-dose whole body imaging, achieved within 13 seconds per image, has enhanced and complemented forensic autopsy practice in Cape Town, a center that deals with about 800 firearm injuries per year.
Martin was followed by Grant P. Tibbetts; Lieutenant Colonel, USAF MC as he presented on future directions of combat imaging in the U.S. Air Force. Dr. Tibbetts is the chief radiology consultant to USAF surgeon general presently serving at RAF Lakenheath in the U.K. Tibbetts presented “Future Combat Imaging,” his vision and philosophy of directions of patient imaging and technology management in theaters of conflict. In this day of rapid aeromedical evacuation, his particular emphasis was on getting the footprint of our imaging right for the tactical situation. This would include declining some of our recent imaging advances where pretty pictures may not be advancing rapid optimal patient management. Examining some of the challenges and advances in various modalities and in workflow in this light, he made some extrapolations regarding the integration of advances where those are likely to advance patient care. CT is an example that has revolutionized imaging impact on patient management as described in more detail by Folio, thought its deployment and use at earlier echelons of care does not promote best outcomes, while adding significantly to footprint and maintenance challenges.
In-theater MRI was assessed as an example with desirable capabilities, but a bridge too far in taking technology where it doesn’t belong. In addition to getting the equipment, right, Tibbetts outlined his view of having the right mix of radiologists on-site for intimate interaction with their surgical colleagues and the provision of interventional services where indicated, while leveraging teleradiology to help provide some specialty services without adding to the footprint. Challenges and anticipated direction in the management of theater images, workload sharing, forwarding of theater examinations for future reference, and archiving of these examinations was reviewed in light of intended goals at present, and lessons learned in the face of present obstacles.
Finally, Tibbetts illuminated the present-day reality of increasing humanitarian aspect and divergent care formulae in currently deployed medical assets such as care conducted on behalf of local nationals who have much longer hospital stays and ongoing imaging needs and follow-up management that cannot easily be transferred to local resources. This is in contrast to rapid evacuation of critical military casualties. This care, however, is a tool of war by other means, an increasing important role of medics in winning friends wherever we find ourselves in service.
After a lunch break/networking session, Dr. Pete Killcommons and Mike Elste, R.T. provided an overview and their experiences of the battlefield teleradiology laydown and infrastructure. The importance of teleradiology in battlefield health care has increased dramatically in the past few years. Their work with Medweb and the continual integrated relationship with the U.S. Army, Navy and Air Force was highlighted and reviewed and included a workstation showing what U.S. radiologists presently use in the theater of operations.
This was followed by Lieutenant Colonel (Ret. USAF) Ed Callaway as he presented on his experiences when he was the Air Force teleradiology consultant. Dr. Callaway presented on combat informatics and discussed challenges and capabilities of teleradiology in austere environments. Callaway is now with NightHawk Radiology Services in Switzerland. The goal of the military radiology-teleradiology network should be to maximize efficiency by recreating, as much as possible, the workflow of a normal radiology practice. Leveraging technologies such as speech recognition, autorouting high-memory capacity teleradiology servers and employment of digital patient identification chips should be utilized. Major impediments in a deployed digital radiology department include lack of a quick method of capturing patient identification in a mass casualty situation, competition for network bandwidth, adequate local image storage capacity and continued use of paper records by radiologists unfamiliar with speech recognition.
Separation of images requiring transmission to evacuation hospitals for comparison and permanent storage from those that do not also optimizes network efficiency. Callaway’s major recommendations were 1) employing personnel ID tags that automate upload of information by bar code, radiosignal or other means, dedicated bandwidth for medical services, 1 TB or greater local site server capacity, digital reporting systems and predeployment training of radiologists with speech recognition and other systems utilized downrange.
Lastly, an interactive panel discussion led by Folio allowed for questions and answers to be addressed dealing with challenges of health care informatics in austere environments. A great dialog took place about the need for a radiologist on site versus remote consultation. Folio believed it was paramount to have a radiologist in the combat hospital from a physician interaction perspective, to include radiologic triage (helping decide who gets imaging first when many are waiting), and Callaway argued that for a majority of civilian applications, off-hours wet-readings can be done remotely very successfully. The consensus here is that presence is driven by individual requirements and situations/environments. This interactive and in-depth focus day examined the challenges of teleradiology in combat, lessons learned from recent operations to future directions of combat imaging. There seemed to be a consensus that advanced imaging in combat casualty care has an uncapped potential. Potential unintended consequences were also discussed such as appropriate allocation of resources, bandwidth, security and power requirements as well.
The workshop was attended by international leaders in the field from eight countries; with backgrounds varying from trauma surgeons, radiologists, flight surgeons, radiologic technologists, and administrators. The conference reviews received excellent ratings and will help guide future battlefield healthcare conferences.
Following this pre-conference workshop, the general session of the Battlefield Healthcare conference was chaired by Tibbetts. It is not surprising that imaging matters as they pertain to the current deployed health care environment continued among the themes that sparked much conversation and networking among the presenters and delegates. Additional themes of note included some which were foreshadowed in the imaging session: excellence in outcomes approaching those in best practices at home; training the way we fight; aeromedical evacuation (in theater and from theater); en-route care; advanced prosthetics and reconstructive surgery; ballistics, protective measures and research; long-term rehabilitation; and the borderlands of post traumatic stress disorder and mild traumatic brain injury. Overall, it was a conference in which the breadth of representation and discussion were outstanding with senior medical leadership present from: Holland, Belgium, Germany, the USA and the U.K. Also present were participants from South Africa, Sweden and Turkey among others. Perhaps as or more important than the presentations were the ideas spawned and relationships formed during networking opportunities over the three days. •
For more information, contact MMT Editor Jeff McKaughan or search our online archives for related stories.